Insurance Terms: Billing Services

Understanding the Explanation of Benefits (EOB) received from your insurance company.

An EOB is a document sent by insurance companies that explains how a claim was processed. Generally, it indicates what was paid and/or what was denied. Most insurance companies use their own format for EOBs. The following table lists some common language and information found on EOBs.

Term

Description

Account Number

A number assigned to each bill by the provider of services; Quest Diagnostics uses the term "Invoice#."

Amount Paid

The portion of the total bill that has been paid by the insurance company.

Allowed Charges

The amount the insurance company approved for processing.

Capitation Accounts

These are clients (HMOs, IPAs, physicians, etc.) who generally pay a fixed rate based on a number of members per month and/or volume of tests. Capitated clients usually provide services for HMOs.

Claim Number

The number assigned by an insurance company to a particular patients bill; this number is often provided on the insurance companys response to Quest Diagnostics.

Coinsurance

The portion of the allowed charges (usually a certain percentage) that is the patients responsibility.

Contract Charges

The portion of the total bill that is NOT owed to Quest Diagnostics (by the insurance company and/or the patient); this amount is based on the contractual agreement between the insurance company and Quest Diagnostics.

Coordination of Benefits

Indicates the amount owed by another insurance company when the patient has additional insurance coverage.

Copay

The amount required to be paid by the patient.

Date of Service

The date on which the laboratory testing was performed.

Deductible

A specific annual dollar amount that must be paid by the patient before the patients insurance will begin reimbursing for covered services.

Excess over UCR

The portion of the total charges that is greater than the allowed charges; this amount is based on the contractual agreement between the insurance company and Quest. "UCR" stands for usual, customary and reasonable.

Explanation of Payment

The section of an EOB that details how payments were made and explains any payment codes used.

IPA

Independent Practice Association

Non-covered

A specific service that is excluded from a contract and is considered non-payable by an insurance company. The patient may be responsible for this amount.

Amount patient owes provider (Quest Diagnostics). This includes "not covered" amounts,"deductible amounts," and any percentage of balance, if payment is less than 100%.Note: Although copays are not a part of this calculation, they are also the patients responsibility.

Provider Information

Payee (Quest Diagnostics) name and mailing address. Additionally, may include account number on the claim, provider number and the name of the provider.

Service Code

A code representing the service provided.

Submitted Charges

The amount Quest Diagnostics billed for service provided.

Units

The number of items included in this service.

UCR

Stands for usual, customary and reasonable and refers to fees for services.